APA Releases 2nd Proposal to Replace GID in the DSM-5

Kelley Winters, Ph.D.
GID Reform Advocates
http://www.gidreform.org
kelley@gidreform.org

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is the medical and social definition of mental disorder throughout North America and strongly influences international nomenclature. There is broad recognition that some kind of diagnostic coding is necessary to facilitate access to medical and/or surgical transition care for those trans and transsexual people who need it. However, the current psychiatric classifications of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the Fourth Edition, Text Revision of the DSM (DSM-IV-TR) fall short of meeting this need and actually contradict transition by describing transition itself as symptomatic of mental disorder.

Today, the Sexual and Gender Identity Disorders Workgroup of the DSM-5 Task Force released a second revision to proposed diagnostic criteria to replace the Gender Identity Disorder category in the DSM-5.

Most significant, the ambiguously defined title of Gender Incongruence has been replaced by Gender Dysphoria (from a Greek root for distress). The work group noted that,

Many commentators recommended ‘gender dysphoria’ as a semantically more appropriate term, because it expresses an aversive emotional component. In this regard, it should be noted that the term ‘gender dysphoria’ has a long history in clinical sexology (see Fisk, 1973) and thus is one that is quite familiar to clinicians who specialize in this area.

A number of trans health organizations and clinicians have advocated nomenclature focused on distress with the wrong physical sex characteristics or the wrong social gender role rather than difference from expectations of assigned birth-sex. Despite some confusion between dysphoria and dysmorphia (delusional self-image) in the press and in the transcommunity, I think dysphoria more clearly communicates distress as the diagnostic focus than alternative terms and represents a positive step forward.

This revised proposal also re-introduces a clinical significance criterion, B, which clarifies that diagnosis requires distress or impairment that meets a clinical threshold. This criterion is present in the DSM-IV but was removed from the first DSM-5 proposal. Clinicians and medical providers who work with  affirmed/transitioned youth have voiced concerns that removal of the clinical significance criterion would further obscure the medical necessity of puberty delaying medications for adolescents who need them, as well as hormonal and surgical transition care later in life. The American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health have issued public statements clarifying the medical necessity of hormonal and/or surgical  transition treatments for those who suffer distress caused by deprivation of physical characteristics congruent with their gender identity, within established standards of care.

However, the specific wording of the clinical significance criterion will likely be debated among community and medical advocates in coming weeks. For example, the proposed wording fails to exclude distress or impairment caused by societal prejudice as a basis for diagnosis. This omission has historically been used to justify gender-reparative therapies on gender nonconforming youth– with an inference that victimhood of intolerance is symptomatic of mental illness.

The first diagnostic criterion is unfortunately unchanged from the first DSM-5 proposal. It ambiguously describes gender identity and a desire for transition related treatment as foci of pathology. The corresponding criterion for children is especially problematic, as it describes gender expression that differs from assigned birth roles as symptomatic of mental illness.

The work group also added a Post-transition specifier, intended to aid continued access to hormonal care after the distress of gender dysphoria has been relieved by transition. However, it will certainly raise controversy by blocking exit from the diagnosis to those whose distress has been successfully relieved by transition related care.

Finally, the work group noted that, “gender diagnoses will be separated from the sexual dysfunctions and paraphilias.” This change in categorical placement of the Gender Dysphoria category would also represent forward progress in the DSM-5, although many advocates and care providers have pushed to move the new diagnosis out of the Sexual and Gender Identity Disorders section altogether.

The second gender category of Transvestic Disorder remains in the DSM-5 proposal, despite broad opposition from the transcommunity, care providers and allies.

The deadline for public comments on this revised proposal is now June 15, 2011. Unfortunately, this will pass before the Symposium of the World Professional Association for Transgender Health (WPATH) in September. WPATH played an active role in providing feedback on the previous proposal in 2010. The DSM-5 Task Force has announced a third round of revisions  and another period of public feedback to follow.

Proposed Diagnostic Criteria for Gender Dysphoria (in Adolescents or Adults)**

See http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=482#

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2* or more of the following indicators: [2, 3, 4]**

1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]

3. a strong desire for the primary and/or secondary sex characteristics of the other gender

4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning,  or with a significantly increased risk of suffering, such as distress or disability**

Subtypes

With a disorder of sex development [14]

Without a disorder of sex development

See also: [15, 16, 19]

Specifier**

Post-transition, i.e., the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female).

Note: Three changes have been made since the initial website launch in February 2010: the name of the diagnosis, the addition of the B criterion, and the addition of a specifier. Definitions and criterion under A remain unchanged.


Proposed Diagnostic Criteria for Gender Dysphoria in Children

See http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=192

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6* of the following indicators (including A1): [2, 3, 4]

1. a strong desire to be of the other gender or an insistence that he or she is the other gender (or some alternative gender different from one’s assigned gender) [5]

2. in boys, a strong preference for cross-dressing or simulating female attire; in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing [6]

3. a strong preference for cross-gender roles in make-believe or fantasy play [7]

4. a strong preference for the toys, games, or activities typical of the other gender [8]

5. a strong preference for playmates of the other gender [9]

6. in boys, a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; in girls, a strong rejection of typically feminine toys, games, and activities [10]

7. a strong dislike of one’s sexual anatomy [11]

8. a strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender [12]

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability.**

Subtypes

With a disorder of sex development [14]

Without a disorder of sex development]

See also [13, 15, 19]

Note: Two changes have been made since the initial website launch in February 2010: the name of the diagnosis and the addition of the B criterion. Definitions and criteria under A remain unchanged.


About gidreform
Kelley Winters, Ph.D.is a writer on issues of transgender medical policy, founder of GID Reform Advocates and an Advisory Board Member for TransYouth Family Advocates. She has presented papers on the psychiatric classification of gender diversity at the annual conventions of the American Psychiatric Association, the American Counseling Association and the Association of Women in Psychology.

11 Responses to APA Releases 2nd Proposal to Replace GID in the DSM-5

  1. Julie in Austin says:

    The difficulty in crafting a single non-controversial set of diagnostic criteria is a reflection of differences in opinion as to what transsexuality and transgenderism is within those communities.

    Any set of diagnostic criteria is going to have its detractors and I scarcely imagine the APA is going to allow itself to become a battleground for differing camps with differing political agendas. On this point I’m reminded of an old joke –

    What’s the difference between a transsexual and a terrorist? You can negotiate with a terrorist.

  2. Pingback: DSM 5 og kjønnsdysfori « Tarald Steins

  3. sophi says:

    i think we need to distinguish diagnostically between the psychological issues associated with being trans and actually being trans.

    because they are two separate issues. if i’m coping well with being trans i shouldn’t have to go to a therapist for months in order to go talk to a doctor about hormone therapy.

  4. Rika says:

    Until transsexualism is purged of pathologizing clinical sexologists and their ilk, there will only be an endless procession of various cobbled, confected, and crafted
    “criteria”. The empirical basis of Transsexualism does not overlap the “magisterium’ of psychopathologizers. These DSM classifications are antagonistic, and explain nothing but the minds and motives of those who concoct them. They serve to impede and turn back the measurable advances that we have made. Facts are facts, they can not be compromised by negotiation. One of the most reprehensible proposals is linked to the steadfast desire to exploit the vulnerable; the unaware; and the misinformed families of trans-children.

  5. HenryHall says:

    On 26 May 2010 WPATH (the acknowledged world’s experts in transgender health) put out an unequivocal statement addressed to the issue of the psychopathologisation of gender.

    WPATH has just been snubbed by the DSM5 Task Force. Not only are it’s views not adopted, the existence of WPATH is simply ignored.

  6. Kris Smith says:

    This is terrible and a severe blow to anyone who wanted to be free of the sexologists who are our lords and masters. Now there is no escape from the label of madness. This also re-introduces sexual orientation into the area through is pathologization of children’s play.

    It looks like Blanchard and his group have pulled a fast one and are now in the process of demonizing us all forever.

  7. Henry, do you know why WPATH maintains a committee with Zucker at its head, or why WPATH signs on to the creation of ‘DSD’ this way? I’d like to hear some answers from WPATH itself but they aren’t talking about their endorsement of Zucker at all.

    • HenryHall says:

      I’m not aware that WPATH has a committee with Dr. Kenneth Zucker as its head. Which committee could that possibly be?

      Zucker’s mentor Blanchard is not a member of WPATH, he resigned his membership some years ago and is not likely to be readmitted.

      • The newly-created committee on “Disorders of Sex Development”.

        http://www.wpath.org/committees_disorders.cfm

        Why does WPATH think it needs to have a committee on Intersex? And what’s even worse is they are using that disgusting, hateful term DSD. It really looks like WPATH took a stand against both trans and intersex with this abomination.

        Zucker a member of WPATH? This is an outrage.

      • HenryHall says:

        You are right, I was unaware.

        The pejorative term “Disorders of Sex Development” is needlessly in-your-face hostile and offensive to all intersex people. It is on a par with having a hypothetical “Colored Committee” to look into why people of African descent are exceptionally vulnerable to heart disease.

  8. HenryHall says:

    Q. And where is WPATH?

    A. Missing inaction, situation normal.

    By putting in a response by June 15,2011 that is anything less than clearly forthright and WPATH will have sealed its fate as an irrelevant organisation / organization.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 74 other followers

%d bloggers like this: